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Medical and Hospital Benefit Exclusions

Benefits are NOT provided for:

  1. Expenses in connection with an injury or sickness that arises from or is sustained in the course of any occupation or employment.
  2. Medical services which are provided by family members. (For example, if your brother is a doctor or dentist and provides services to you, the claim will be denied.)
  3. Cosmetic surgery, except operations necessary to repair or alleviate disfigurement due to an accident and except for treatment of a congenital defect in a Dependent Child or except for breast reconstruction following mastectomy.
  4. Supplies or services:
    1. For which no charge is made
    2. For which the person is not required to pay
    3. Furnished by a hospital or facility operated by the U. S. Government or any authorized agency of the U.S. Government or furnished at the expense of such Government or agency with the exception of Veterans Administration hospitals where the charges are for a non-service related illness or injury
    4. Which are provided without cost by any municipality, county, or other political subdivision
    5. For court-ordered hospital care
  5. Drugs, drug treatments and medical procedures not approved by the Food and Drug Administration (FDA) including, but not limited to, compounded medications, experimental drugs or drugs exceeding the FDA’s recommended daily dosage.
  6. Expenses from injuries incurred in accidents involving a third party to the extent recovery is made.
  7. Non-prescription medications or medical supplies (over the counter items) unless otherwise covered under the prescription drug benefit.
  8. Services or supplies where no charge is made by the provider.
  9. Charges in excess of the Reasonable and Customary charge, where applicable.
  10. Charges for chelation therapy except in cases of acute arsenic, gold, mercury or lead poisoning.
  11. Personal items while in the hospital.
  12. Routine eye care for which benefits are provided through the Vision Service Plan.
  13. Educational materials and home care instructions other than for diabetic training and home healthcare services.
  14. Fees for filling out forms or copying medical records or fees for special reports.
  15. Laser eye surgery unless you meet the Plan’s laser surgery requirements.
  16. Charges for the following orthotic items:
    • Pre-made, non-custom foot orthotics
    • Spinal pelvic stabilizers
    • Arch supports or heel wedges
    • Shoes unless attached to a brace or if needed due to the diagnosis of severe foot disease
  17. Any bodily injury or sickness for which you are not under the care of a doctor.
  18. Conditions caused by or arising out of an act of war, armed invasion or aggression.
  19. Human Chorionic Gonadotropins (hCG) injections.
  20. Claims received over one year from the date the service was rendered.
  21. Expenses incurred for artificial insemination, in-vitro fertilization (IVF), Zygote intrafallopian organ transfer (ZIFT), gamete intrafallopian transfer (GIFT), intracytroplasmic sperm injection (ICSI), and similar procedures, or treatment of infertility, including drugs used to treat infertility.
  22. Weight control programs or surgeries that do not meet the Plan’s requirements.
  23. Liposuction.
  24. B-12 injections for most diagnoses.
  25. Charges not related to an illness or injury.
  26. Hair loss treatment.
  27. Ambulance transportation for the patient’s convenience.
  28. Educational programs or vision therapy to correct learning disabilities such as dyslexia and similar problems.
  29. Chiropractic treatment for Dependent Children under 16 years of age.
  30. Doctors’ additional charge for “Sunday/Holiday” and “after hour” visits.
  31. Expenses for a full body scan or a virtual colonoscopy.
  32. Chemical skin peeling or other non-medically necessary skin treatments.